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Date run 1/28/2011 11:28:40AI SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report R5021 <br /> Run by 5290Page2 <br /> `►" Facility Information as of 1/28/20./ <br /> Record Selection Criteria: Facility ID FAD009750 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned ovmer,operator or agent of same,acknowledge that all site,and/or project spec.PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the parry identified as the OWNER on this form. I also carbly that all operations wall be performed in accordance with all applicable Ordinace Codes andlor Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />